Page 27 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

In the context of a claim or lawsuit, the audit trail does not play favorites.

Unfortunately, for many providers, the audit trail is unforgiving. The record
is what the record is, and the audit trail will either support the provider’s

position or sink it. If, for example, a radiology report was available to
the provider prior to the patient’s discharge, but the report was never

reviewed, the audit trail will establish this fact. Similarly, if the standard of
care (as established by expert testimony) requires a radiologist to spend

a certain amount of time reviewing studies, and the radiologist actually
spent significantly less time performing that review than was required by

the standard of care, this will be borne out by the audit trail.

Because every keystroke in an electronic system is recorded with a
time and date stamp, alterations should never be made to the record or

report after a claim or lawsuit is asserted. Amendments, supplementation,
corrections, and addendums made after an adverse event will also likely

be viewed suspiciously and as self-serving. It should be remembered that
the Forensic IT experts who will be reviewing the metadata (audit trail),

will do so at a much later time; typically, immediately prior to trial. If a
correction to the electronic record or report must be made for continuity

of care purposes, and there is no claim or lawsuit pending or threatened,
these corrections should be made in the same manner as with paper

charts (i.e., clearly identifying that it is a correction or supplementation,
the reason necessitating the change, the date, and who made the

change).

Additionally, electronic documentation should be performed

contemporaneous with the event or as close thereto
as possible. The audit trail will reveal the time

differential between the event taking place and
the recording of the event. If significant time is

allowed to elapse, the accuracy of the provider’s
documentation will be called into question.

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